Variation in anticoagulation for atrial fibrillation between English clinical commissioning groups: an observational study

Abstract

Background: Despite improvement in anticoagulation for atrial fibrillation (AF), substantial variation in anticoagulation persists between clinical commissioning groups (CCGs) and regions in England.

Aim: To identify reasons for variation between English CCGs in anticoagulation for AF.

Design and setting: A 4-year observational study from 2012/2013 to 2015/2016, of the national Quality and Outcomes Framework.

Method: Multiple regression and Pearson's correlation coefficients were used to analyse anticoagulation for AF in relation to older age, Index of Multiple Deprivation, prescription of non-vitamin K antagonist oral anticoagulants (NOACs), and exception reporting, as well as stroke hospital admission and mortality.

Results: The proportion of eligible patients in England prescribed anticoagulants for AF without exceptions for clinical complexity or patient dissent increased from 65.1% in 2012/2013 to 77.9% in 2015/2016. In 2015, 290 920 additional eligible people were anticoagulated in association with use of the CHA₂DS₂VASc rather than CHADS₂ score. From 2012 to 2015, exception reporting almost halved from 20% to 10.2%. Variation in CCG anticoagulation was not associated with deprivation or NOAC use. There was a strong negative association between exception reporting representing patient complexity and anticoagulation performance, accounting for 57% of the variation in anticoagulation without exceptions (multiple regression coefficient = -0.81; 95% confidence intervals = -0.92 to -0.71; P<0.001).

Conclusion: Anticoagulation for AF has improved substantially in England in association with considerable increases in the eligible population as a result of decreased exception reporting and the use of the CHA₂DS₂VASc score. There is still substantial room for improvement in most CCGs because, even allowing for exceptions, nine out of 10 CCGs failed to achieve 90% anticoagulation.

Keywords: anticoagulation; atrial fibrillation; primary care; stroke.

Figure 1.

Atrial fibrillation QOF AF007. Percentage of exceptions to anticoagulation by CCG, in relation to proportion on anticoagulation without exceptions. AF = atrial fibrillation. CCG = clinical commissioning group. QOF = Quality and Outcomes Framework.

Figure 2.

Proportion of people with atrial fibrillation CHA2DS2VASc score ≥2 on anticoagulation. Distribution in English CCGs by region with and without exceptions 2015/2016. CCG = clinical commissioning group.